Delayed Diagnosis: Tuberculous Arthritis of Right Knee Joint in a Patient with Rheumatoid Arthritis

Background. Though skeletal tuberculosis (TB) accounts about 3% of all TB cases, it occupies 10–35% of extrapulmonary TB cases. Common osteoarticular sites involved include the spine (40%), hip (25%), and knee (8%). Co-occurrence of rheumatoid arthritis (RA) and tuberculous arthritis involving peripheral joint is rarely reported in the literature. Case Presentation. We present a case of 42-year-old Sri Lankan-Sinhalese male with right knee joint pain and swelling for one-year duration. This patient had a history of long-standing RA with interstitial lung disease for which he was on multiple immunosuppressive medications including methotrexate, sulfasalazine, leflunomide, mycophenolate mofetil, and prednisolone. His knee joint aspiration fluid was positive for both acid fast bacilli (AFB) and polymerase chain reaction for TB (TB-PCR). He was started on anti-tuberculous chemotherapy. Conclusion. TB should be considered as an important differential diagnosis for chronic mono-arthritis of knee joint with a high degree of suspicion, particularly where TB is endemic.

Machine learning to identify lung cancer with tuberculosis from isolated tuberculosis (Preprint)

UNSTRUCTURED Tuberculosis (TB) is a precipitating cause of lung cancer. Lung cancer patients coexisting with TB is difficult to differentiate from isolated TB patients. The aim of this study is to develop a prediction model in identifying those two diseases between the comorbidities and TB. In this work, based on the laboratory data from 389 patients, 81 features, including main laboratory examination of blood test, biochemical test, coagulation assay, tumor markers and baseline information, were initially used as integrated markers and then reduced to form a discrimination system consisting of 31 top-ranked indices. Patients diagnosed with TB PCR ＞1mtb/ml as negative samples, lung cancer patients with TB were confirmed by pathological examination and TB PCR ＞1mtb/ml as positive samples. We used Spatially Uniform ReliefF (SURF) algorithm to determine feature importance, and the predictive model was built using machine learning algorithm Random Forest. For cross-validation, the samples were randomly split into four training set and one test set. The selected features are composed of four tumor markers (Scc, Cyfra21-1, CEA, ProGRP and NSE), fifteen blood biochemical indices (GLU, IBIL, K, CL, Ur, NA, TBA, CHOL, SA, TG, A/G, AST, CA, CREA and CRP), six routine blood indices (EO#, EO%, MCV, RDW-S, LY# and MPV) and four coagulation indices (APTT ratio, APTT, PTA, TT ratio). This model presented a robust and stable classification performance, which can easily differentiate the comorbidity group from the isolated TB group with AUC, ACC, sensitivity and specificity of 0.8817, 0.8654, 0.8594 and 0.8656 for the training set, respectively. Overall, this work may provide a novel strategy for identifying the TB patients with lung cancer from routine admission lab examination with advantages of being timely and economical. It also indicated that our model with enough indices may further increase the effectiveness and efficiency of diagnosis.

Tuberculous Thyroiditis Post COVID-19 Infection

Thyroid tuberculosis (TT) is a rare disease and can be a diagnostic challenge. Here we highlight a case of TT following COVID-19 infection. A 38-year Myanmar immigrant female presented with nocturnal fever, fatigue, nausea, sore throat, appetite and weight loss for 1 week with dysphagia, neck swelling, dyspnea, and watery diarrhea. Medical history included renal transplant due to ESRD from IgA nephropathy, DM and treated latent TB with no prior or family history of thyroid disease. She had COVID 7 months ago, complicated by allograft rejection. She was tachycardic, febrile but not in acute distress. Neck exam revealed diffuse thyromegaly with tenderness on right lobe without bruit, palpable cervical lymphadenopathy nor tremors. Labs showed WBC 12.8x109/L (4.8-10), and ESR 50 ml/hr (20-40). On admission, she developed AKI and immunosuppressant meds were discontinued. She was started on broad-spectrum antibiotic. CT chest reported moderate loculated right pleural effusion with mid and lower lobe consolidation. Blood and urine culture, pleural fluid, sputum culture for acid-fast bacilli (AFB) and QuantiFERON-TB were negative. Upon persistent fever, RIPE therapy (rifampin, isoniazid, pyrazinamide, ethambutol) was started and stopped after 10 days due to transaminitis and negative TB PCR. Further labs showed TSH 0.04 mIU/ml (0.27-4.2), FT4 2.81 ng/dl (0.93-1.7), TT3 127 ng/dl (80-200), negative TPO and TSI. Endocrinology was consulted for thyroiditis. Ibuprofen and Propranolol were initiated with continuation of prednisone. Repeat thyroid labs normalized in 4 days. US thyroid noted diffuse, heterogenous thyromegaly without hypervascularity or abscess. CT neck showed diffuse thyromegaly 4.2x7.2x7.5 cm in size; right thyroid lobe extended to posterior clavicle with enhanced capsule, without discrete lymph node or vascularity changes, suggestive of thyroiditis. Fine needle aspiration (FNA) of left thyroid lobe drained 3 ml purulent fluid and AFB were seen on direct smear. She was diagnosed as TT, but unable to restart RIPE therapy due to worsening liver function. She expired after cardiac arrest due to intracranial bleeding and brain abscess. Thyroid tuberculosis is a rarely reported clinical entity. This is the first reported case of secondary TB (TT) in post-COVID infected patient from reactivation of latent TB. In our case, follicular destruction caused initial hyperthyroidism with later recovery. It can be difficult to distinguish subacute from suppurative thyroiditis due to TB. Imaging may not always show clear abscess formation. FNA is crucial for diagnosis, and drainage of any abscess. Anti-TB meds can be given, surgery is rarely required. TT should be considered in any immunocompromised patient with fever and neck pain. Imaging should also include evaluation for any CNS spread of TB. Early detection and treatment will help reduce significant morbidity and mortality.

A Meta-analysis and systemic review study: PCR to diagnose localized pulmonary and extra pulmonary Tuberculous Infections.

TB ranks as the second leading cause of death from an infectious disease worldwide. Rapid diagnosis and treatment are pivotal for the effective management and control of TB in clinical practice. However, the inherent limitations make it difficult to meet the requirement for early diagnosis. The Aim to this Meta-analysis study was to understand use of the polymerase chain reaction for the detection of Mycobacterium tuberculosis (TB PCR) as a basis for making diagnostic and clinical decisions and to understand sensitivity of TB PCR for the same. The aim to TB-PCR as a diagnostic tool is to rule out the other though efficient yet time consuming methods to diagnose Tb infections, as these methods delay the clinical decision making and further treatment.

“ROLE OF TB PCR IN CLINICALLY DIAGNOSED AND TREATED CASES OF TUBERCULAR PLEURAL EFFUSION”.

Background: Tuberculosis is still a major health problem worldwide. It is estimated that about one-third of the world's population is infected with mycobacterium tuberculosis. While pulmonary tuberculosis is most common presentation; pleural effusion is one of the common complications of primary tuberculosis or in conjunction with pulmonary infiltrate typical of post primary tuberculosis. Diagnosis of pleural tuberculosis (TB) remains a challenge due to its nonspecific clinical presentation and paucibacillary nature.TB PCR is a self-automated method from Roche for the detection of mycobacterium tuberculosis. This test allows for detection and identification of MTB from direct specimens within 24 – 48 hours of the receipt in the laboratory. We determined the role of TB PCR in diagnosis of tubercular etiology in pleural effusion in our study. Materials and methods: Prospective and analytical studyin a tertiary care centre of the study area was conducted after Ethics Committee permission. The study period was from June 2018 to December 2019.Data of 36tubercular pleural effusion patients was retrieved. Role of TB PCR in the diagnosis of tubercular etiology was assessed. Results: Pleural fluid samples collectedwere sent for various investigations like Routine microscopy, cytology, Pleural fluid pH, protein, LDH and TB PCR. Serum protein and serum LDH were also done.The diagnosis of Tubercular Pleural Effusion was made by clinical examination, radiological presentation, results of pleural fluid investigations and response to Anti Tubercular treatment collectively. Out of the 36 patients diagnosed to have tubercular pleural effusion, 8(22%) patient’s pleural fluid TB PCR report was positive. Conclusion:TB PCR is not a useful test in the diagnosis of tubercular etiology in pleural effusion.

Tuberculous Pericarditis with tamponade in COVID-19: A case report

IntroductionTuberculous pericarditis is a rare manifestation of tuberculosis infection. COVID-19 pandemic poses a challenge in detecting uncommon disease. Pericardial effusion with tamponade has been described with COVID-19 but the association with tuberculosis is not yet known. Case presentationA 47-year-old man was admitted with symptoms of COVID-19 infection. Rapid progression of cardiomegaly on radiograph with clinical deterioration were suggestive of pericardial tamponade. Urgent pericardiocentesis revealed hemoserous fluid, elevated adenosine deaminase and positive TB PCR. He was started on steroid, anti-tuberculous therapy and Remdesivir with marked improvement of symptoms. Repeat echocardiogram and CT Thorax showed resolution of pericardial fluid and patient was discharged well. ConclusionsThis case highlights the difficulty in detecting a concomitant rare but important disease. The development of massive pericardial tamponade acutely is not pathognomonic for COVID-19, and a careful diagnostic process involving multi-modality imaging, occurred to arrive at a diagnosis of tuberculosis.

A Ten-Year Retrospective Study on the Clinical Features and Outcomes of Pediatric Intestinal Tuberculosis Admitted in UP-Philippine General Hospital

Objective. To describe the clinical, biochemical, microbiologic, radiologic and histological features and outcome of intestinal TB.Methods. Medical records of patients diagnosed with intestinal TB were reviewed. Cases were considered bacteriologically-confirmed if intestinal tissue was positive on smear culture or polymerase chain reaction (PCR); and clinically-diagnosed if with clinical, histologic, and radiologic evidence of extra-pulmonary TB. Results. Fifteen patients [Mean (SD) age: 13 (4) years; 53% females] were included. One was bacteriologicallyconfirmed; and fourteen were clinically-diagnosed. Fever (87%) and abdominal pain (73%) were commonly seen. Seven (47%) had anemia, 5 (33%) leukocytosis and 10 (71%) hypoalbuminemia. Eleven (73%) were positive on smear or TB PCR of various specimens. Nine of 10 (90%) patients with an abdominal CT scan had thickening of bowel loops. Three with intestinal biopsy demonstrated caseation granuloma. Fourteen patients were given quadruple anti-TB medications. Six had surgery, 8 had no disease-related complications, 4 died of sepsis and 3 were lost to follow up.Conclusion. Intestinal TB presents with non-specific clinical and laboratory features. Radiologic findings may provide a clue to the diagnosis. Histologic confirmation in intestinal tissue was only seen in a few cases. The prognosis was favorable for patients who completed the anti-TB treatment.

Tubercular pyometra in a young unmarried female - dilemma and pitfalls in diagnosis: a rare case report with review of literature

This rare case is the first case being reported as tubercular pyometra in a young unmarried woman. Diagnosis of genital tuberculosis which is a form of EPTB (extra pulmonary TB) can be baffling, compelling a high index of suspicion owing to paucibacillary load in the biological specimens. A negative smear for acid-fast bacilli, lack of granuloma on histopathology and failure to culture mycobacterium tuberculosis do not exclude the diagnosis of EPTB. A 25-year-old unmarried, government employee from Bihar presented to our OPD with secondary amenorrhea for two months carrying with her an USG, CT and MRI done in Bihar suggesting enlarged uterus with fluid collection. CT-also reported few enlarged lymph nodes. Her preoperative investigations revealed an elevated ESR and x-ray chest was normal. Dilatation was done under ultrasonic guidance in OT and 150 cc of thick caseous material was drained A gentle curettage was done on lateral wall near cornea and both the caseous material and endometrial tissue was sent for gram staining, TB-PCR (polymerase chain reaction), NAAT (nucleic acid amplification techniques) and culture. In the post-operative period gram staining for AFB, NAAT, TB-PCR all came negative and it was difficult to convince patient to take ATT. However, on day 10, HPE report came as granuloma suggestive of TB and patient was put on ATT. Culture too was reported negative later. Paucibacillary female genital TB (FGTB) is difficult to diagnose because of varied presentation and limitations of diagnostic tests A raised ESR is presumptive but non-specific. Other tests are x-ray chest, HSG, endometrial tissue for TB PCR nucleic acid amplification techniques (NAAT, HPE and culture (conventional or Bactec). Patients with EPTB are, however, more likely to have negative sputum smear results and many EPTB cases do not have direct lung involvement. Currently, there are no standard guidelines or algorithm for the diagnosis of FGTB. Female genital TB has varying presentation and diagnosis is difficult because of the paucibacillary nature.